What it means when a long-term care insurance claim is refused on grounds of a pre-existing medical condition, non-disclosure or concealment: what the company is actually alleging, what to check in the health declaration and the policy, and why this is a situation that calls for a legal review.
Starting point: this is the kind of refusal that calls for the most care
Let us say this at the outset and explicitly: a refusal based on an allegation of a pre-existing medical condition or non-disclosure is not like a functional refusal. It is an allegation of a legal character, and sometimes it goes to the validity of the policy itself.
If you have received a letter like this, our recommendation is to seek a legal review and not to rely on support alone. We are not a law firm and we do not give legal advice, and this is exactly the kind of situation in which that distinction matters.
This page is intended to explain what is actually being alleged, what is worth collecting before you seek advice, and what not to do — so that you do not damage your position without realising it.
What the company is actually alleging
Behind the various formulations there are usually two possible allegations, each with a different meaning.
The first allegation is a pre-existing medical condition: that the condition on which the claim is based already existed before the insurance started, and therefore falls within the policy's exclusion. That is an allegation about the scope of cover.
The second allegation is non-disclosure: that on joining the insurance, medical information that should have been given was not given — in a health declaration or a questionnaire. That is an allegation about the validity of the contract itself, and its consequences are more serious.
Sometimes the letter mixes the two, or uses general wording. It is important to identify exactly what is being alleged, because the examination is entirely different.
What to collect before seeking advice
The more organised you are when you arrive at the advice meeting, the more effective it will be. These are the documents almost always needed in this situation.
- The insurance proposal and the health declaration signed on joining
- The full text of the policy, including the exclusion clauses
- The refusal letter in full, including all its appendices
- The medical documents the company relied on, if they were identified
- Medical documentation from the period before joining the insurance
- Documentation of the date the functional condition actually began
- All earlier correspondence with the company about the claim
Points worth checking
Without going into legal analysis, there are a few factual questions worth clarifying. The answers will serve whoever examines the file.
Was a health declaration signed at all? In some group covers, joining is done without full medical underwriting, and that changes the picture.
If one was signed — what exactly was asked in it? A general question and a specific question are not the same. The question of who actually filled in the form, and whether the insured person understood the questions, may also be relevant.
And finally: is there a real connection between the medical condition mentioned and the present long-term care condition? Not every earlier diagnosis is necessarily connected to the functional decline that led to the claim.
What not to do
There are a few steps that may do harm, and people take them out of a wish to cooperate and resolve the matter quickly.
- Do not sign waiver, settlement or policy cancellation documents before a review
- Do not hold telephone conversations in which you describe the medical history orally
- Do not send further medical documents before it is clear which are needed and why
- Do not concede in general terms along the lines of "perhaps we did not know to mention it"
- Do not put off the review — deadlines matter
What you can still do in parallel
Even where the file calls for a legal review, there is factual work that helps and that you can do in parallel.
You can put together an organised timeline: when they joined the insurance, what diagnoses preceded that, when the functional change began and when the claim was filed. A clear timeline is usually the first thing anyone reviewing the case asks for.
You can also check whether there are additional covers that were not examined. In a fair number of cases another policy — with different joining conditions — may be relevant and may not be subject to the same allegation.
Frequently asked questions
What is a refusal on grounds of a pre-existing medical condition?
An allegation by the insurance company that the condition on which the claim is based already existed before the insurance started, and therefore falls within the policy's exclusion. It is an allegation about the scope of cover.
What is the difference between a pre-existing condition and non-disclosure?
A pre-existing condition goes to the scope of cover. Non-disclosure is an allegation that on joining, medical information that should have been given was not given, and it goes to the validity of the contract itself — which makes it more serious.
Does a refusal like this require a lawyer?
We clearly recommend seeking a legal review. This is an allegation of a legal character that sometimes goes to the validity of the policy, and it is not purely factual work.
What should we not do after receiving a letter like this?
Do not sign waiver or settlement documents, do not describe the medical history on the telephone, do not send further documents before it is clear what is needed, and do not put off the review — deadlines matter.
If we never filled in a health declaration at all — does that make a difference?
It may well do. In some group covers, joining is done without full medical underwriting, and that is a fact relevant to the review. It is worth clarifying whether a declaration was signed and what was asked in it.
Can we do anything in parallel with the legal review?
Yes. You can put together an organised timeline of the date of joining, the preceding diagnoses, the start of the functional change and the date of filing, and check whether there are additional covers that were not examined.
Official sources for further checking
This is general information and does not replace personal medical, legal or insurance advice. Eligibility is determined by the documents and rules that apply to each case.
